Anderson Nursing Assessment- Vital Signs, Pain And Nursing Process

1. An assessment must be completed on the patient prior to determining a nursing diagnosis.

True

False

In order to determine a nursing diagnosis for a patient, it is necessary to first complete an assessment. This assessment involves gathering information about the patient's health status, medical history, symptoms, and any other relevant factors. This information helps the nurse to identify the patient's needs and potential problems, which can then be used to formulate a nursing diagnosis. Without a thorough assessment, it would be difficult to accurately determine the appropriate nursing diagnosis for the patient. Therefore, it is true that an assessment must be completed before determining a nursing diagnosis.

Explanation

In order to determine a nursing diagnosis for a patient, it is necessary to first complete an assessment. This assessment involves gathering information about the patient's health status, medical history, symptoms, and any other relevant factors. This information helps the nurse to identify the patient's needs and potential problems, which can then be used to formulate a nursing diagnosis. Without a thorough assessment, it would be difficult to accurately determine the appropriate nursing diagnosis for the patient. Therefore, it is true that an assessment must be completed before determining a nursing diagnosis.

2. The blood pressure cuff that is selected to use on the patient may provide an inaccurate result if the incorrect size is chosen.

True

False

If the incorrect size of blood pressure cuff is chosen, it may provide an inaccurate result. This is because the cuff needs to fit properly around the patient's arm in order to accurately measure their blood pressure. If the cuff is too small, it may give a falsely high reading, while if it is too large, it may give a falsely low reading. Therefore, choosing the correct size of cuff is important to ensure accurate blood pressure measurement.

Explanation

If the incorrect size of blood pressure cuff is chosen, it may provide an inaccurate result. This is because the cuff needs to fit properly around the patient's arm in order to accurately measure their blood pressure. If the cuff is too small, it may give a falsely high reading, while if it is too large, it may give a falsely low reading. Therefore, choosing the correct size of cuff is important to ensure accurate blood pressure measurement.

3. Pain is what the patient says it is.

True

False

This statement emphasizes the subjective nature of pain and acknowledges that the patient's perception and description of their pain should be trusted and respected. Pain cannot be objectively measured or quantified, so the patient's own experience and description of their pain are the most reliable indicators. This approach is crucial for effective pain management and ensuring that patients receive appropriate treatment and support.

Explanation

This statement emphasizes the subjective nature of pain and acknowledges that the patient's perception and description of their pain should be trusted and respected. Pain cannot be objectively measured or quantified, so the patient's own experience and description of their pain are the most reliable indicators. This approach is crucial for effective pain management and ensuring that patients receive appropriate treatment and support.

4. What scale would you use to assess pain in an alert and oriented adult patient?

FLACCS scale

FACES scale

Numeric (1-10), verbal

CPOT

The numeric (1-10), verbal scale is commonly used to assess pain in alert and oriented adult patients. This scale allows the patient to rate their pain on a scale from 1 to 10, with 1 being the least amount of pain and 10 being the most. The verbal component allows the patient to describe their pain using words such as mild, moderate, or severe. This scale is easy to use and provides a standardized way to assess and communicate pain levels in adult patients.

Explanation

The numeric (1-10), verbal scale is commonly used to assess pain in alert and oriented adult patients. This scale allows the patient to rate their pain on a scale from 1 to 10, with 1 being the least amount of pain and 10 being the most. The verbal component allows the patient to describe their pain using words such as mild, moderate, or severe. This scale is easy to use and provides a standardized way to assess and communicate pain levels in adult patients.

5. If the patient is clean and well dressed they are probably healthy

True

False

The statement "If the patient is clean and well dressed they are probably healthy" is not necessarily true. A person can appear clean and well dressed but still have underlying health issues or be suffering from a chronic illness. Physical appearance does not always reflect a person's overall health condition. Therefore, the answer is false.

Explanation

The statement "If the patient is clean and well dressed they are probably healthy" is not necessarily true. A person can appear clean and well dressed but still have underlying health issues or be suffering from a chronic illness. Physical appearance does not always reflect a person's overall health condition. Therefore, the answer is false.

6. The ___________ temperature is measured in the armpit.

The correct answer is axilla, axillary. The axilla refers to the armpit area, and axillary is the adjective form of axilla. Therefore, the temperature measured in the armpit is referred to as axillary temperature.

Explanation

The correct answer is axilla, axillary. The axilla refers to the armpit area, and axillary is the adjective form of axilla. Therefore, the temperature measured in the armpit is referred to as axillary temperature.

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7. ______________ is the component of the nursing process in which the nurse makes the decision that the current issue is resolved or requires further nursing interventions.

Assessment

Diagnosis

Outcome /planning

Interventions

Evaluation

Evaluation is the component of the nursing process in which the nurse assesses whether the current issue has been resolved or if further nursing interventions are required. It involves gathering data, analyzing the effectiveness of the interventions implemented, and determining the outcomes achieved. This step is crucial in ensuring that the patient's goals are met and that the nursing care provided is effective.

Explanation

Evaluation is the component of the nursing process in which the nurse assesses whether the current issue has been resolved or if further nursing interventions are required. It involves gathering data, analyzing the effectiveness of the interventions implemented, and determining the outcomes achieved. This step is crucial in ensuring that the patient's goals are met and that the nursing care provided is effective.

8. A care plan informs the physician what he needs to address with the patient an their family.

True

False

A care plan is a document that outlines the specific healthcare needs and goals of a patient. It is typically created by a team of healthcare professionals, including physicians, nurses, and other specialists. While the care plan may inform the physician about the patient's needs, it is not solely for the physician's benefit. The care plan serves as a guide for all members of the healthcare team, including the patient and their family, to ensure that everyone is on the same page and working towards the same goals. Therefore, the statement that a care plan informs the physician what he needs to address with the patient and their family is false.

Explanation

A care plan is a document that outlines the specific healthcare needs and goals of a patient. It is typically created by a team of healthcare professionals, including physicians, nurses, and other specialists. While the care plan may inform the physician about the patient's needs, it is not solely for the physician's benefit. The care plan serves as a guide for all members of the healthcare team, including the patient and their family, to ensure that everyone is on the same page and working towards the same goals. Therefore, the statement that a care plan informs the physician what he needs to address with the patient and their family is false.

9. The five vital signs are temperature, blood pressure, pulse, __________ and pain.

The question asks for the missing vital sign that completes the list of five. The options provided are "respirations, breathing, breaths." These options all refer to the same vital sign, which is the measurement of the number of breaths a person takes per minute. Therefore, the correct answer is "respirations, breathing, breaths."

Explanation

The question asks for the missing vital sign that completes the list of five. The options provided are "respirations, breathing, breaths." These options all refer to the same vital sign, which is the measurement of the number of breaths a person takes per minute. Therefore, the correct answer is "respirations, breathing, breaths."

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10. General appearance includes which of the following components as part of the assessment? (Mark all that apply)

Grooming

Odor

Skin color

Conversive

Nail polish

General appearance includes grooming, odor, and conversive as part of the assessment. Grooming refers to the overall cleanliness and tidiness of a person's appearance, including their hair, clothing, and personal hygiene. Odor refers to any noticeable smells or body odors that may be present. Conversive refers to the individual's ability to engage in conversation and communicate effectively. Skin color and nail polish are not typically considered components of general appearance assessment.

Explanation

General appearance includes grooming, odor, and conversive as part of the assessment. Grooming refers to the overall cleanliness and tidiness of a person's appearance, including their hair, clothing, and personal hygiene. Odor refers to any noticeable smells or body odors that may be present. Conversive refers to the individual's ability to engage in conversation and communicate effectively. Skin color and nail polish are not typically considered components of general appearance assessment.

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